INDIVIDUAl CASE AUDIT

(ONLY FOR MEDICAL AUDIT COMMITEE)

STRICTLY CONFIDENTAL
Part I
Patient Identification
Name ___________________________________, Age: _______, Sex _______
Adress __________________________________________________________
__________________________________________________________
C.R. No. ________________________, Type of Admission: Routine/Emergency
D. O. A. ________________________, Time ___________________________
MLC/NON-MLC
D.O.D. _________________________, Time ___________________________
Duration of stay in hospital __________________________________________
Part II
Department ______________________________, Unit ____________________
Ward and Bed No. _________________________________________________
Consultant I/C __________________________, Sr. Resident _______________
Provisional Diagnosis ______________________________________________
Final Diagnosis ___________________________________________________
Part III
1. General State of Medical Record:
i.

Face sheet

complete/incomplete
ii.

Form

properly fiiled/not properly

filled
iii.

Nurse notes

adequate
iv.

Doctors Progress notes and treatment

adequate/not

written in propr order and form:

Yes/No

2. Length of Stay:
i.

Total stay _________________________________________________

ii. Pre-op. stay _______________________________________________

iii. Post-op. stay _______________________________________________
iv. Stay was prolonged ____________________________________ Yes/No
v. Reasons for prolonged stay ___________________________________
a. Delay in investigation?

Yes/No

b. Delay in surgery?

Yes/No

c. Pre-op. infection?

Yes/No

d. Post-op. infection?

Yes/No

e. Complications?

Yes/No

f. Administrative reason?

Yes/No

3. Investigations:
i.

Do laboratory findings support the

final diagnosis?

ii.

Yes/No/NA

Are lab. Investigations sufficient

in relation to the ailment?

iii.

Yes/No/NA

Do Rdiological findings support

the final diagnosis?

iv.

Yes/No/NA

Are imaging investigations sufficient

in relation to the ailment?

v.

Yes/No/NA

Any delay in getting the investigations

done or in reporting?

Yes/No/NA

4. Treatment:
i.

Was the treatment given to this patient

generally acceptable?

ii.

Yes/No/NA

Whether any treatment given to this

patient was superflous?

iii.

Yes/No/NA

Was the treatment (including antibiotic

usage) reviewed at required interval?

Yes/No/NA

5. Surgery:
i.

Whether there was an adequate

indication for surgery?

ii.

Yes/No/NA

Whether any normal tissue or

organ removed?

iii.

Yes/No/NA

Was the tissue/organ removed during

surgery sent for histo-path?

iv.

Yes/No/NA

Does histopath report agree with

the diagnosis?

v.

Yes/No/NA

Are

the

Pre-op.

notes

written

adequately?

anesthesia

notes

adequate?

for

in

Yes/No/NA
vi.

Are

the

the

consent

Yes/No/NA
vii.

Is

surgery

proper

order?

Yes/No/NA
viii. Are the operation notes adequate?
ix.

Any

Yes/No/NA
Post-op.

infection?

Yes/No/NA
a. Type of infection? = ______________________________________
b. When detected? = _______________________________________
c. Was it avoidable? = ______________________________________
x.

Any

Post-op.

complication?

Yes/No/NA
xi.

Did the patient die post-op.?

If yes,
a. How many days after surgery? = ____________________________
b. Cause of death? = _______________________________________
c. Was it expected? = ______________________________________

6. Complication:
If any, developed during the hospital stay

due to treatment or which could have

been avoided?

Yes/No/NA

7. Discharge:
i.

Was

the

patient

discharged

in

proper

time?

Yes/No/NA
ii.

Discharge summery?

Adequate/Not

adequate
8. Death:
i.

Was the patients death expected and

Justifiable?

ii.

Yes/No/NA

Was the patients death in relation to the

nature of his ailment?

iii.

Yes/No/NA

Was

autopsy

done?

Yes/No/NA
iv.

Do the autopsy finding tally with the

clinical diagnosis?

v.

Yes/No/NA

Death

certificate?

Complete/Incomplete
9. In case of Casualty Admission?
i.

Was the patient given immediate

treatment?

ii.

Yes/No/NA

How long did the patient stay in the

Casualty Department before admission
to the ward? =

iii.

Any

delay

in

treatment?

Yes/No/NA
10. Relating to Hospital Administration:
i.

Was

there

any

delay

Yes/No/NA
of any equipment/instrument/drug
which adversely affected the diagnosis,

or

non-availability

treatment or progress of the case?

C.R. No. = Case Record Number
D.O.A. = Date of Admission (Arrival)
MLC = Medico-Legal Case
NON-MLC
D.O.D. = Date of Discharge
NA = Not Adwquate
(Sumber bacaan: Prakash, A; Bhardwaj, D.: Medical Audit, 2011)